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2012| April-June | Volume 15 | Issue 2
Online since
April 16, 2012
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ORIGINAL ARTICLES
Intrathecal morphine is superior to intravenous PCA in patients undergoing minimally invasive cardiac surgery
Chirojit Mukherjee, Eva Koch, Joergen Banusch, Markus Scholz, Udo X Kaisers, Joerg Ender
April-June 2012, 15(2):122-127
DOI
:10.4103/0971-9784.95075
Aim of our study was to evaluate the beneficial effect of low dose intrathecal morphine on postoperative analgesia, over the use of intravenous patient controlled anesthesia (PCA), in patients undergoing fast track anesthesia during minimally invasive cardiac surgical procedures. A randomized controlled trial was undertaken after approval from local ethical committee. Written informed consent was obtained from 61 patients receiving mitral or tricuspid or both surgical valve repair in minimal invasive technique. Patients were assigned randomly to 2 groups. Group 1 received general anesthesia and intravenous patient controlled analgesia (PCA) pump with Piritramide (GA group). Group 2 received a single shot of intrathecal morphine (1.5 μg/kg body weight) prior to the administration of general anesthesia (ITM group). Site of puncture was confined to lumbar (L1-2 or L2-3) intrathecal space. The amount of intravenous piritramide used in post anesthesia care unit (PACU) and the first postoperative day was defined as primary end point. Secondary end points included: time for tracheal extubation, pain and sedation scores in PACU upto third postoperative day. For statistical analysis Mann-Whitney-U Test and Fishers exact test (SPSS) were used. We found that the demand for intravenous opioids in PACU was significantly reduced in ITM group (
P
<0.001). Pain scores were significantly decreased in ITM group until second postoperative day (
P
<0.01). There was no time delay for tracheal extubation in ITM group, and sedation scores did not differ in either group. We conclude that low dose single shot intrathecal morphine provides adequate postoperative analgesia, reduces the intravenous opioid consumption during the early postoperative period and does not defer early extubation.
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Infusion of low-dose vasopressin improves left ventricular function during separation from cardiopulmonary bypass: A double-blind randomized study
Ahmed Said Elgebaly, Mohab Sabry
April-June 2012, 15(2):128-133
DOI
:10.4103/0971-9784.95076
We aimed to investigate whether low-dose vasopressin administered to patients undergoing coronary artery bypass grafting (CABG) surgery with preexisting mild to moderate systolic dysfunction can produce sustained improvement in cardiac function. This double-blind randomized study was conducted in a hospital where a single anesthetic and surgical team performed elective CABG. Twenty patients aged 32-61 years who underwent elective CABG between January 2007 and December 2007 were enrolled in this study. The patients randomly received either vasopressin 0.03 IU/min (Group A) or normal saline (Group B) in equal volume for 60 min after cardiopulmonary bypass (CPB). The cardiac output, cardiac index, stroke volume index, fractional area of contraction and systemic vascular resistance index were significantly higher in Group A than in Group B. Adrenaline (mean dose: 0.06 μg/kg•min-1) was required in seven patients from Group B but in none of the Group A patients on initial separation from CPB (P< 0.05). Of the 10 patients in Group B, five required phenylepherine to maintain the mean arterial pressure (MAP) >65 mmHg, whereas none of the Group A patients required phenylephrine for MAP regulation (P< 0.05). We conclude that Infusion of low-dose vasopressin for patients with mild to moderate left ventricular systolic dysfunction during separation from CPB is beneficial for the postoperative hemodynamic profile, reduces the catecholamine doses required and improves left ventricular systolic function.
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A randomized prospective analysis of alteration of hemostatic function in patients receiving tranexamic acid and hydroxyethyl starch (130/0.4) undergoing off pump coronary artery bypass surgery
Murali Chakravarthy, Geetha Muniraj, Swapnil Patil, Sharadaprasad Suryaprakash, Sona Mitra, Benak Shivalingappa
April-June 2012, 15(2):105-110
DOI
:10.4103/0971-9784.95072
Postoperative hemorrhagic complications is still one of the major problems in cardiac surgeries. It may be caused by surgical issues, coagulopathy caused by the side effects of the intravenous fluids administered to produce plasma volume expansion such as hydroxyl ethyl starch (HES). In order to thwart this hemorrhagic issue, few agents are available. Fibrinolytic inhibitors like tranexamic acid (TA) may be effective modes to promote blood conservation; but the possible complications of thrombosis of coronary artery graft, precludes their generous use in coronary artery bypass graft surgery. The issue is a balance between agents that promote coagulation and those which oppose it. Therefore, in this study we have assessed the effects of concomitant use of HES and TA. Thromboelastogram (TEG) was used to assess the effect of the combination of HES and TA. With ethical committee approval and patient's consent, 100 consecutive patients were recruited for the study. Surgical and anesthetic techniques were standardized. Patients fulfilling our inclusion criteria were randomly allocated into 4 groups of 25 each. The patients in group A received 20 ml/kg of HES (130/0.4), 10 mg/kg of T.A over 30 minutes followed by infusion of 1 mg/kg/hr over the next 12 hrs. The patients in group B received Ringer's lactate + TA at same dose. The patients in the Group C received 20 ml/kg of HES. Group D patients received RL. Fluid therapy was goal directed. Total blood loss was assessed. Reaction time (r), α angle, maximum amplitude (MA) values of TEG were assessed at baseline, 12, 36 hrs. The possible perioperative myocardial infraction (MI) was assessed by electrocardiogram (ECG) and troponin T values at the baseline, postoperative day 1. Duration on ventilator, length of stay (LOS) in the intensive care unit (ICU) were also assessed. The demographical profile was similar among the groups. Use of HES increased blood loss significantly (
P
< 0.05). Concomitant use of TA reduced blood loss when used along with HES. r value was prolonged at 12 hours in all the groups and α angle was reduced at 12 hours in all the groups, where as MA value was reduced at 12
th
hour in the HES group compared to the baseline and increased in TA + HES group. These findings were statistically significant. No significant change in Troponin T values/ ECG, duration of ventilation and LOS ICU was observed. No adverse events was noticed in any of the four groups. HES (130/0.4) used at a dose of 20 ml/kg seems to produce coagulopathy causing increased blood loss perioperatively. Hemodilution produced by fluid therapy seems to produce Coagulopathy as observed by TEG parameters. Concomitant use of TA with HES appears to reverse these changes without causing any adverse effects in patients undergoing OPCAB surgery.
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REVIEW ARTICLE
Transesophageal echocardiography: Instrumentation and system controls
Mahesh Prabhu, Dinesh Raju, Henning Pauli
April-June 2012, 15(2):144-155
DOI
:10.4103/0971-9784.95080
Transesophageal echocardiography (TEE) is a semi-invasive, monitoring and diagnostic tool, which is used in the perioperative management of cardiac surgical and hemodynamically unstable patients. The low degree of invasiveness and the capacity to visualize and assimilate dynamic information that can change the course of the patient management is an important advantage of TEE. Although TEE is reliable, comprehensive, credible, and cost-effective, it must be performed by a trained echocardiographer who understands the indications and the potential complications of the procedure, and has the ability to achieve proper acquisition and interpretation of the echocardiographic data. Adequate knowledge of the physics of ultrasound and the TEE machine controls is imperative to optimize image quality, reduce artifacts, and prevent misinterpretation of diagnosis. Two-dimensional (2D) and Motion (M) mode imaging are used for obtaining anatomical information, while Doppler and Color Flow imaging are used for information on blood flow. 3D technology enables us to view the cardiac structures from different perspectives. Despite the recent advances of 3D TEE, a sharp, optimized 2D image is pivotal for the reconstruction. This article describes the relevant underlying physical principles of ultrasound and focuses on a systematic approach to instrumentation and use of controls in the practical use of transesophageal echocardiography.
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ORIGINAL ARTICLES
Occluding the pulmonary artery to improve detection of patent foramen ovale during ventricular assist device placement
Jiapeng Huang, Michale J Bouvette
April-June 2012, 15(2):118-121
DOI
:10.4103/0971-9784.95074
Unrecognized patent foramen ovale (PFO) in patients after left ventricular assist device (VAD) placement could cause significant hypoxemia and paradoxical embolism. We aim to improve the techniques for PFO detection in this patient population before left ventricular device initiation. We evaluated the effects of main pulmonary artery occlusion on patients' hemodynamic and detection of PFO by transesophageal echocardiography (TEE). We compared between the standard and pulmonary artery occlusion technique. Sixty-two patients with ASA physical status class IV were studied. They presented with end-stage heart failure for left VAD placement. All patients received both Valsava maneuver and occlusion of their pulmonary arteries to assess their influence on detection of PFO. Occlusion of the main pulmonary artery consistently increased right atrial to left atrial pressure gradient. The PFO detection rate using TEE was significantly improved from 0% to 10% by this maneuver compared with the Valsava maneuver. Occlusion of the main pulmonary artery is a simple and effective method to improve PFO detection by TEE before left VAD initiation.
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INTERESTING IMAGES
Anomalous ridge on the left atrial side of the atrial septum
Yukitaka Shizukuda, James Muth, Curtis Chaney, Mehran Attari
April-June 2012, 15(2):161-162
DOI
:10.4103/0971-9784.95083
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LETTERS TO EDITOR
Thoracic epidural anesthesia in elderly patients undergoing cardiac surgery for mitral regurgitation feasibility study
Fabrizio Monaco, Camilla Biselli, Monica De Luca, Giovanni Landoni, Rosalba Lembo, Alberto Zangrillo
April-June 2012, 15(2):164-165
DOI
:10.4103/0971-9784.95085
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Inadvertent placement of left central venous catheter into left internal thoracic vein: A case report
Rajesh Angral, Parameswaran Sabesan, Kanagaraj Natarajan, Benjamin Ninan
April-June 2012, 15(2):165-166
DOI
:10.4103/0971-9784.95086
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CASE REPORTS
Anesthetic implications of total anomalous systemic venous connection to left atrium with left isomerism
Parimala Prasanna Simha, Muralidhara Danappa Patel, AM Jagadeesh
April-June 2012, 15(2):134-137
DOI
:10.4103/0971-9784.95077
Total anomalous systemic venous connection (TASVC) to the left atrium (LA) is a rare congenital anomaly. An 11-year-old girl presented with complaints of palpitations and cyanosis. TASVC with left isomerism and noncompaction of LV was diagnosed after contrast echocardiogram and computed tomography angiogram. The knowledge of anatomy and pathophysiology is essential for the successful management of these cases. Anesthetic concerns in this case were polycythemia, paradoxical embolism and rhythm abnormalities. The patient was successfully operated by rerouting the systemic venous connection to the right atrium.
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INTERESTING IMAGES
Trans-esophageal echocardiography: An indispensible guide for transcatheter device closure of ruptured sinus of Valsalva aneurysm
Anju Sarupria, Poonam Malhotra Kapoor, Neeti Makhija, Usha Kiran
April-June 2012, 15(2):156-157
DOI
:10.4103/0971-9784.95081
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LETTERS TO EDITOR
Tracheal injury causing massive air leak during mitral valve replacement surgery
Arindam Choudhury, Neeti Makhija, Usha Kiran
April-June 2012, 15(2):171-172
DOI
:10.4103/0971-9784.95090
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ORIGINAL ARTICLES
Pre-operative Tei Index does not predict left ventricular function immediately after mitral valve repair
Chirojit Mukherjee, Steffen Groeger, Maurice Hogan, Markus Scholz, Udo X Kaisers, Joerg Ender
April-June 2012, 15(2):111-117
DOI
:10.4103/0971-9784.95073
Echocardiographic assessment of systolic left ventricular (LV) function in patients with severe mitral regurgitation (MR) undergoing mitral valve (MV) repair can be challenging because the measurement of ejection fraction (EF) or fractional area change (FAC) in pathological states is of questionable value. The aim of our study was to evaluate the usefulness of the pre-operative Tei Index in predicting left ventricular EF or FAC immediately after MV repair. One hundred and thirty patients undergoing MV repair with sinus rhythm pre- and post-operatively were enrolled in this prospective study. Twenty-six patients were excluded due to absence of sinus rhythm post-operatively. Standard transesophageal examination(IE 33,Philips,Netherlands) was performed before and after cardiopulmonary bypass according to the guidelines of the ASE/SCA. FAC was determined in the transgastric midpapillary short-axis view. LV EF was measured in the midesophageal four- and two-chamber view. For calculation of the Tei Index, the deep transgastric and the midesophageal four-chamber view were used. Statistical analysis was performed with SPSS 17.0. values are expressed as mean with standard deviation. LV FAC and EF decreased significantly after MV repair (FAC: 56±12% vs. 50±14%, P<0.001; EF: 58±11 vs. 50±12Έ P<0.001). The Tei Index decreased from 0.66±0.23 before MV repair to 0.41±0.19 afterwards (P<0.001). No relationship between pre-operative Tei Index and post-operative FAC or post-operative EF were found (FAC: r=−0.061, P=0.554; EF: r=−0.29, P=0.771). Conclusion: Pre-operative Tei Index is not a good predictor for post-operative FAC and EF in patients undergoing MV repair.
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INTERESTING IMAGES
Disappearing ring in chest cavity
Vijish Venugopal, R Mahadevan
April-June 2012, 15(2):163-163
DOI
:10.4103/0971-9784.95084
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CASE REPORTS
Dilated ascending aorta is associated with the difficulty in correct placement of pulmonary artery catheter
Mukesh Tripathi, Mamta Pandey
April-June 2012, 15(2):138-140
DOI
:10.4103/0971-9784.95078
The present case report highlights that a tense mega-sized aortic root and ascending aorta can mechanically resist the passage of fully inflated (1.5 ml air) balloon to wedge-trace position in the pulmonary artery. Any attempt to push the catheter rather predisposed its recoiling and rebutting into the right ventricle and the cardiac arrhythmia. Inflating continuous cardiac output catheter balloon with lesser volume of air (1 ml) is suggested to overcome this problem.
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Iatrogenic hemorrhage from left umbilical vein after cardiac surgery: An unusual complication
Vivek Chowdhry, Banabihari Mishra, KVRS Rao
April-June 2012, 15(2):141-143
DOI
:10.4103/0971-9784.95079
Postoperative bleeding is a concern for all patients undergoing heart surgery, which could be due to surgical causes or coagulation disorder. The patients at risk for coagulopathy include those patients with complex or prolonged procedures, those exposed to preoperative anticoagulants and, to a lesser extent, patients with a preoperatively elevated prothrombin time and activated clotting time. However, intraabdominal bleeding after cardiac surgery is rare (0.3-2%). As the mortality rate of patients exposed to these complications is high (11-59%), timely recognition and prompt management is vital for patient's safety and for avoidance of postoperative complications. Here, we present a case of free intraabdominal hemorrhage as sequelae of pacing wire insertion in open heart surgery and its successful management.
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EDITORIAL
Journey forward
Praveen Kumar Neema
April-June 2012, 15(2):103-104
DOI
:10.4103/0971-9784.95071
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INTERESTING IMAGES
Cardiac computed tomography as a diagnostic tool for coronary artery aneurysm following percutaneous coronary intervention
Anshuman Darbari, Devender Singh, Shekhar Tandon
April-June 2012, 15(2):158-160
DOI
:10.4103/0971-9784.95082
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LETTERS TO EDITOR
Sinus venosus atrial septal defect in a patient with Pentalogy of Fallot
Sarvesh P Singh, Sandeep Chauhan, Sachin Talwar
April-June 2012, 15(2):166-168
DOI
:10.4103/0971-9784.95087
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Hitting back HIT
Dilip Gude
April-June 2012, 15(2):168-169
DOI
:10.4103/0971-9784.95088
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Perioperative management of pulmonary atresia with intact ventricular septum in a 5-year old
Mazen Faden
April-June 2012, 15(2):169-171
DOI
:10.4103/0971-9784.95089
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Inflow occlusion on beating heart: How long and how?
Orhan Gokalp, Ismail Yurekli, Levent Yilik, Ali Gurbuz
April-June 2012, 15(2):172-173
DOI
:10.4103/0971-9784.95091
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